EXECUTIVE SUMMARY OF TASK MANAGERS REPORT
Human health appears in the very first principle of the Rio
Declaration on Environment and Development, adopted by the world
community at the 1992 Earth Summit:
Human beings are at the centre of concern for
sustainable development. They are entitled to a healthy
and productive life in harmony with nature.
Human health is essential for sustainable development since
without health, human beings would not be able to combat poverty
or care for their environment; in turn, care of the environment
is essential for the sustenance of human well being and the
development process. Human health is dependent on the
environment itself being healthy.
Thus it is not surprising that improved health, which is the
focus of Chapter 6, is to be found throughout Agenda 21. It is
at the centre of the major developmental strategies for (i)
combating poverty, (ii) developing and disseminating knowledge
concerning the links between demographic trends and factors and
sustainable development, (iii) promoting sustainable human
settlement development and (iv) promoting the full, equal and
beneficial integration of women in all development activities.
It is equally a central concern of other major programmes of
Agenda 21: water, atmosphere, housing, agriculture, toxic
chemicals, and hazardous and radioactive wastes.
At the global level, Agenda 21 is beginning to lead to new
health-related developments in a number of agencies. But most
agencies are continuing along well established lines
incorporating issues of sustainable development in a pragmatic
way. Many of these policies, while not directly linked with
Agenda 21, are of sufficient importance to be reported on in that
context. As it is felt to be too early in the implementation of
Chapter 6 of Agenda 21 to try to distinguish between what can or
cannot be linked with the Earth Summit, these directions are
included in this report.
Chapter 6 of Agenda 21 identified the essential activities
that need to be implemented. But Chapter 6 did not address the
fact that much reform is needed for such a programme of
activities to be realizable. Four "lines of reform" emerge from
the analysis undertaken in preparing this report:
(1) Community (Health) Development: protecting and
educating vulnerable groups as part of more holistically
conceived community development programmes;
(2) Health Sector Reform: Ministries of Health increasing
allocation of resources to most cost-effective programmes;
(3) Environmental Health: increasing understanding of
sectoral-linkages with health and mobilizing action in other
sectors accordingly;
(4) National Decision-Making and Accounting: strengthening
health representation in national decision-making and
incorporating health and its financing in new accounting systems
for sustainable development.
Fortunately steps have already been taken to promote reform
within the health sector, as shown in this report. The
additional reforms are needed to ensure that health is
incorporated in all aspects of national sustainable development.
Only in this manner will the pursuit of improved human health be
a positive driving force for sustainable development.
The CSD called upon the Task Managers to prepare "analytic"
reports which would highlight "unnecessary duplication", "gaps
and opportunities for cooperation and joint programming",
"assessment of relevance, strength and usefulness of various
programmes and activities", and "organizational responsibilities
and allocation of tasks on the basis of expertise and competitive
advantage". This has been done, but only to a partial degree.
The analysis has not been carried out to its "logical
conclusion", since any conclusion concerning, for example,
"unnecessary duplication" might be counterproductive.
It was felt that a logical delineation of organizational
responsibilities might stall current efforts among UN agencies to
support health sector reform. Without health sector reform, it
is difficult to imagine the other reforms identified having any
chance of success. Instead, the CSD is called upon to help the
process of change by confirming that the lines of reform
identified should be actively pursued by all relevant UN
agencies.
The CSD can further stimulate movement in the direction
outlined through special action, e.g. calling upon Governments to
host meetings to elaborate the reform process in more detail,
calling upon donor agencies to ear-mark funds for this process in
countries that are actively implementing sustainable development
policies, and establishing special working groups to monitor
progress within the UN system to ensure that the reform called
for at national level is leading to comparable reform within and
among the various agencies involved.
A common understanding of sustainable development does not
exist. Consequently there is a strong risk that the
revolutionary changes called for by Agenda 21 will rapidly be
lost sight of. This risk is particularly present in the health
sector where environmental health has rarely received adequate
attention. The active support of the CSD is required in carrying
out the reforms listed above to ensure that the full potential of
Agenda 21 is realized.
TASK MANAGERS REPORT
CHAPTER 6: PROTECTING AND PROMOTING HUMAN HEALTH
INTRODUCTION
The Task Managers report has been prepared by WHO in
collaboration with FAO, IAEA, ILO, ITU, UNCHS, UNDP, UNEP,
UNESCO, UNFPA, UNICEF, UNIDO, UNRWA, WFP, the World Bank and WMO,
and with the assistance of the UNDPCSD.
This report covers the five programme areas that constitute
Chapter 6 of Agenda 21:
A. Meeting primary health care needs, particularly in
rural areas
B. Control of Communicable Diseases
C. Protecting Vulnerable Groups (Infants and children,
youth, women, and indigenous people and their communities)
D. Meeting the Urban Health Challenge
E. Reducing Health Risks from Environmental Pollution and
Hazards
Other major programmes that contribute to human health, e.g.
those of human settlement, agriculture and rural development,
freshwater resources, and environmentally sound management of
toxic chemicals and hazardous wastes are not discussed as such
although there is considerable inter-connectedness with these
programmes which is reflected in this review.
This report is organized along the following lines:
(1) current agency and inter-agency activities and future
directions envisaged with respect to each of the above
programmes;
(2) scientific and technological means and human resources
development and capacity-building that are common to these
programmes; and,
(3) the decision-making and financial implications of the
action plan of Chapter 6.
The report ends with an indication of priority future
strategies for consideration by the Commission on Sustainable
Development during its May 1994 session.
SECTION I: HEALTH AND SUSTAINABLE DEVELOPMENT - GLOBAL POLICY
UPDATE
Human health appears in the very first principle of the Rio
Declaration on Environment and Development, adopted by the world
community at the 1992 Earth Summit:
Human beings are at the centre of concern for
sustainable development. They are entitled to a
healthy and productive life in harmony with nature.
Human health is essential for sustainable development since
without health, human beings would not be able to engage in
development, combat poverty and care for their environment; in
turn, care of the environment is essential for the sustenance of
human well being and the development process. Human health is
dependent on the environment itself being healthy.
Thus it is not surprising that improved health, which is the
focus of Chapter 6, is to be found throughout Agenda 21. It is
at the centre of the major developmental strategies for (i)
combating poverty, (ii) developing and disseminating knowledge
concerning the links between demographic trends and factors and
sustainable development, (iii) promoting sustainable human
settlement development and (iv) promoting the full, equal and
beneficial integration of women in all development activities.
It is equally a central concern of other major programmes of
Agenda 21: water, atmosphere, housing, agriculture, toxic
chemicals, and hazardous and radioactive wastes.
At the global level, Agenda 21 is beginning to lead to new
health-related developments in a number of agencies. But most
agencies are continuing along well established lines
incorporating issues of sustainable development in a pragmatic
way. What follows are statements by each agency concerning
"protecting and promoting human health".
WHO has developed a global strategy in 1993 for health and
environment which provides a new orientation for
multi-disciplinary and multi-sectoral efforts to ensure that
health considerations are fully incorporated and at the core of
all development and environmental activities, from policy
planning to project implementation, monitoring and evaluation.
This strategy establishes a unifying framework for WHO action and
provides the basis for WHO programmes at Headquarters, in
Regional Offices and in countries to respond to Agenda 21.
UNEP, in cooperation with WHO and other agencies, and
through its International Register of Potentially Toxic
Chemicals, the Industry and Environment Office, among others, has
been providing member states with information on the health and
environmental effects of chemical and physical agents;
information on legal status of chemicals; incorporation of
environmental measures for the control of vector-borne diseases;
cleaner production technologies and preventing and preparedness
of accidents; information on global trends in contamination of
air, food and water through its Global Environment Monitoring
System (GEMS); promotion of supportive environments for health;
and in capacity building.
The publication of the World Banks World Development Report
of 1993 on Health and Development, which was prepared with the
support of the WHO, represents a major development for the health
sector. It illustrates the importance of health to national
development and outlines reforms needed to achieve more
cost-effective use of resources available for health.
UNDP's health sector constitutes approximately 3 per cent of
overall IPF expenditures. UNDP's emphasis continues to be on
training of all levels of health personnel and improvement of
management capacity. UNDP action is inextricably linked to the
multi-sectoral objectives which characterize UNDP's overall human
development approach. In particular, the poverty/environment
links to traditional health sector priorities will receive more
emphasis in the future. Clean drinking water and sanitation
activities will also continue to receive high priority within the
linked areas of poverty and disease prevention.
One of the major goals of FAO is to help member governments
provide their populations with a safe, high quality, nutritious
and stable food supply. FAO pursues this goal by promoting
sustainable agriculture and rural development (SARD), promoting
the production of safe and nutritious food through the
application of good agricultural and manufacturing practices
(e.g. the integrated pest management and plant nutrition
systems), reducing the use of unjustified sanitary and
phytosanitary barriers to international trade in agricultural
products, and promoting food quality control systems which
protect the economic interest and health of consumers.
UNCHS (Habitat) is mandated to facilitate solutions,
especially for low-income communities, which will improve the
living environment and promote better health among rural and
urban communities. The underlying purpose of Habitat's human
settlements activities is capacity building.
UNESCO's has recognized the need to strengthen its action in
developing countries to improve the health and nutrition
conditions of school-age children many of whom are frequently
burdened by high levels of morbidity associated with infections
and communicable diseases that are readily transmissible in
unhealthy school environments. UNESCO approaches educational
participation and the health of school-age children through
interdisciplinary and intersectoral cooperation both among its
specific areas of concern - education, social and human sciences,
natural sciences, culture and communication - and in its work
with other agencies.
UNFPA is the largest multilateral agency for population
assistance. It has continued to increase its support to MCH/FP
activities in the developing world. The following UNFPA goals
for MCH and family planning are expected to be achieved during
the final decade of this century:
* to increase contraceptive prevalence in the developing
countries to 59 per cent.
* to reduce infant mortality rates to at least below 50
per 1000 live births in all countries and also among major
sub-groups within countries, and
* to reduce maternal mortality by at least 50 per cent,
especially in areas where the current figure exceeds 100 per
100,000 births.
ITU's emphasis continues to be on the promotion of
telecommunications and broadcasting in developing countries.
Such technology offers a powerful tool to ensure that health
messages penetrate society as a whole. As this technology
becomes more widely available, it should contribute to improved
management of local health services and more informed community
participation.
UNIDO's technical co-operation programme contributes to
protecting and promoting human health through the transfer of
technology and training in pharmaceutical and health care
industries including, for example, promoting the local
manufacturing of vaccines and essential drugs. UNIDO's programme
on environment addresses almost all aspects of the environmental
pollution caused not only by industry but also by other human
activities.
WFP's current commitment to the health sector totals over
$570 million. In providing support to national health
programmes, WFP contributes to improved food intake either
through direct feeding of malnourished children and hospital
patients or by providing take-home food supplies to expectant or
nursing mothers and small children.
In December, 1992 FAO and WHO held the International
Conference on Nutrition (ICN) which recognized that health is an
essential element of human development which required the action
of many social and economic sectors in addition to the health
sector. If further noted that improved nutrition, and thus
health, requires the coordinated efforts of relevant government
ministries, agencies and offices with mandates for agriculture,
fisheries, and livestock, food, health, water and public works,
supplies, planning, finance, industry, education, information,
social welfare and trade.
Various aspects of the effects and impact of climate and its
variability and potential change on human well-being and health
is dealt with in a joint project between WHO, WMO and UNEP.
* * *
At the national level, Agenda 21 is only beginning to affect
the health sector in a handful of countries. This is not
surprising as the activities called for by Agenda 21 are wide
ranging, cutting across many sectors and involving different
technical disciplines. Most national Ministries of Health are
responsible for implementing only a part of the health-related
activities outlined in Agenda 21. For example, health services
in urban areas generally fall under the responsibility of the
local municipal authorities, while the provision of environmental
services, e.g. water and sanitation, are often in another public
sector.
Human health depends on the promotive and protective
programmes which stem from all public sectors. The health
sector, as such, is only responsible for a limited number of
these programmes. Furthermore, curative services account for the
major part of the human, material and financial resources
available to the health sector. Preventive services are weak,
and health inputs into development work of other sectors,
including industry, agriculture, education, local government,
etc., are hampered by lack of critical staff such as
environmental epidemiologists and health policy analysts. In the
current economic crisis, preventive and promotive services of the
health sector must struggle to keep afloat as national health
budgets are reduced. Health promoting work of other sectors is
equally constrained by reduced public funds. These economic
difficulties are particularly present in countries where
environmental degradation and increasing health vulnerability is
most severe.
Thus, Chapter 6 of Agenda 21 represents an extraordinary
challenge to governments and the UN system. How the various
agencies of the UN system support the implementation of the
programme areas identified in Chapter 6 clearly can serve to help
governments meet this challenge successfully.
In the next section, current activities of the UN system are
briefly reviewed and indications given of the major future
directions envisaged including constraints. No attempt has been
made to provide a complete review of relevant ongoing activities;
rather, an effort has been made to provide indicative examples of
current programmes and policies with particular attention to
those health programmes most conditioned by environmental
factors. No effort has been made to assess activities undertaken
by individual governments in response to Agenda 21.
SECTION II: REVIEW OF PROGRAMME AREAS
A. MEETING PRIMARY HEALTH CARE NEEDS, PARTICULARLY IN RURAL AREAS
ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM
At the level of international health policy, there have been
major shifts in recognizing the importance of investment in the
social sector and the environment which have opened up
opportunities for broader intersectoral actions for health. These
shifts started with the Alma-Ata conference on PHC in 1978 and
the adoption by WHO of the Health for All goal with its emphasis
on social justice. More recently, the publication of World Bank
reports on Poverty in 1991, Development and the Environment in
1992, and Investing in Health in 1993, are a reflection of this
change in emphasis.
WHO's Second Evaluation report of the implementation of the
Global Strategy for Health for All by the Year 2000 noted that
there has been "strong political commitment to achieving health-
for-all goals, and most countries have endorsed at the highest
level the health-for-all policies and strategies". However, it
is also reported that these policies and strategies "have not
always been put into practice in appropriate ways by the
countries when attempting to facilitate universal access to
essential health care with all eight essential elements of PHC on
a continuing basis". The report also drew attention to the
growing awareness of environmental problems and their impact on
health. The imbalance of basic resources such as water between
developed and developing countries was found to be contributing
to the increase in poverty and population growth and to the
widening gap between the rich and the poor.
The 1993 World Development Report on Investing in Health
examined the "interplay between human health, health policy, and
economic development". While recognizing that investing in
health is one means of accelerating development because good
health increases the economic productivity of individuals and the
economic growth of countries, the report indicates that a radical
reform of the health sector is needed to achieve this end. Such
a reform would lead governments to redirect their spending away
from specialized care and toward "packages" of public health
measures and essential clinical care which are most
cost-effective in terms of reducing burden of disease.
UN agencies and bilateral donors are deeply involved in
efforts to improve the capacities of district health systems
including those of other related institutions such as local
government. WHO, jointly with UNDP, and other agencies have
supported the promotion of the District Health Systems concept
with emphasis on collecting country experiences and supporting
studies and R&D. WHO has produced a series of guidelines which
are serving as the basis for implementing such programmes.
Efforts have been undertaken to improve management performance of
health centres and hospital, concentrating on their roles and
function in the district health system.
District health systems have improved in a number of
countries, but in most cases limited to a number of districts.
Most success has been achieved in countries which have been
politically and economically stable over the past fifteen years.
The continuing and prolonged economic crisis in all regions of
the world has hampered extending progress more widely.
District health systems aim at achieving an equitable
distribution of health resources through the provision of health
services, intersectoral action and community participation.
Intersectoral action is particularly relevant for improving
health through environmental changes (water, sanitation and
housing), through better food supplies and through raising
educational and socioeconomic status. It is not unusual,
however, for intersectoral coordination to be weak, for example
as regards an adequate supply of safe water and sanitation, even
though this is one of the eight essential elements of PHC as
defined at Alma-Ata.
The inclusion of drinking-water supply and sanitation as one
of the major programme areas in Chapter 18 of Agenda 21
(Protection of the Quality and Supply of Freshwater Resources)
should help broaden efforts which aim to achieve the goal of
universal access to water supply and sanitation. So important is
this area that several UN agencies are involved in one way or
another: WHO and UNICEF in the expansion of basic services; UNHCR
and UNRWA in serving refugee populations; UNESCO in attending to
the basic needs of school children; UNDP as part of over all
development. Recent inter-agency efforts to integrate the
various freshwater activities into a more comprehensive approach
include the International Conference on Water and the
Environment, held in Dublin in January 1992, and the FAO, UNICEF,
UNDP, World Bank and WHO Technical Consultation on Integrated
Rural Water Management, held in Rome in March 1993.
Community action for health, which is the theme of the
Technical Discussions organized in conjunction with the 47th
World Health Assembly of WHO in 1994, remains an essential
principle of the PHC approach. Related community based
initiatives which complement the provision of services through
PHC include: Primary Environmental Care (PEC), UNCHS' Settlement
Infrastructure and Environment and Community Development
Programmes, UNESCO's Education for All programme, and FAO's
Community Nutrition Programme.
PEC is a process by which communities - with varying degrees
of external support - organize themselves and strengthen, enrich
and apply their own means and capacities (know-how, technologies
and practices) for the care of their environment while
simultaneously satisfying their needs. PEC is emerging as an
important instrument that NGOs and various UN agencies are
looking to as a means of improving the quality of life of people
through environmental regeneration.
UNESCO's interdisciplinary and inter-agency cooperation
project on the environment, population, health, education and
information for human development is being developed in response
to 'education for all', environment and development, population
education and the emerging perspectives suggested by UNCED
through Agenda 21. This initiative can provide valuable support
in terms of more participatory information, education and
communication to increase people's knowledge and skills relevant
to health and the environment.
Recognizing the crucial role of small farmers and their
organizations in programmes for environmental protection, FAO has
introduced participatory approaches in many of its field
programmes, and is engaged in promoting 'people's participation'
projects in 15 countries.
FUTURE DIRECTIONS
Experience has demonstrated that sustainable health systems
based on PHC cannot be achieved without the full participation of
communities and other sectors working in a district. This
partnership is the only means by which a commitment, achieved
through common objectives and priorities, can ensure that the
resources needed to address health and environment issues are
obtained. Decentralization and democratization are opening up
new possibilities for community participation, including
increased self-reliance in health.
At the local level, people and communities view health and
environmental problems in holistic rather than in segmented
('sectoral') terms. At this level, intersectoral cooperation
becomes feasible on the basis of common interests. Linkages
between health and other social sectors (such as education) can
often be achieved on the basis of common actions and projects
that can furnish a strong basis for sustained cooperation.
Harmonious working relationships can be fostered between
community health workers and other developmental workers (e.g.,
education, agriculture, public works, etc.).
The implementation of PHC has been and continues to be
pursued as a set of special vertical programmes, contrary to the
integrative and holistic intent of Alma-Ata. Some multi as well
as bilateral funding agencies continue to give emphasis to the
eradication or reduction of diseases through such programmes,
although some have now shown themselves to be unsustainable.
Without addressing this basic conceptual hurdle and reorienting
the approach to external agency support, difficulties will
persist in the development of sustainable and responsive health
infrastructures essential to implement PHC in the context of a
supportive environment.
Adding to these difficulties is the fact that rapidly
evolving market oriented economics, in the context of newly
decentralized and democratized States, has contributed to the
fragmentation of services and threatened equity, intersectoral
collaboration and community participation. In many developing
countries, there is a growing trend towards private medical
practices and the independent sale of pharmaceutical products in
rural communities. These, together with the introduction of fees
for services at government health centres and hospitals, has had
the effect of diminishing the utilization of health services
particularly among the poorest and most vulnerable members of the
communities in the least developed countries. These developments
carry with them serious negative consequences for sustainable
healthy environments as the poor without support continue to
degrade the environment and natural resources in the area where
they live, undermining food production and livelihood prospects.
Some of the problems identified above can be addressed in
part through the current efforts of health sector reform taking
place in many countries. These reforms emphasize the changing
roles of Government in health, shifting from managing and
financing health services to coordinating health work. At
another level, there is increased recognition that external
support to the development of the district health system must
have an integrated approach addressing the need to build
capacities not only of the health services themselves but also of
other health related institutions such as local governments,
community development committees, etc. The methods and managerial
tools required for developing and sustaining these capacities
require attention.
WHO has begun work with the World Bank and UNDP to create a
Network for Capacity Building in Health Sector Reform. The focus
of the proposed network is on information exchange, tools
development and advocacy. The network can be an important means
for pooling expertise, linking people with similar visions and
motivation and thus breaking the isolation many professionals
charged with designing and monitoring reform efforts are facing.
B. CONTROL OF COMMUNICABLE DISEASES
ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM
A number of major disease-related goals have been formulated
through extensive consultation in various international forums
attended by virtually all Governments, relevant United Nations
organizations, and a number of NGOs. These were identified in
Chapter 6 of Agenda 21; they remain in force.
ECOSOC has placed the subject of "coordination of the
activities of the United Nations system in the fields of
preventive action and intensification of the struggle against
malaria and diarrhoeal diseases, in particular cholera" on its
agenda. The Council stressed the importance of national
capacity- building - to food safety, nutrition, drinking water
and sanitation, hygiene, education, especially women and, in
general, to targeted investments for a better infrastructure in
the health sector.
The managerial review of the WHO Programme for the Control
of Diarrhoeal Diseases (CDD) is entrusted to a committee made up
of representatives of 4 UN agencies: UNDP, UNICEF, WHO and the
World Bank. In compliance with ECOSOC recommendations, there are
plans to extend involvement in CDD programme management to other
UN agencies whose activities may contribute to the prevention of
diarrhoeal diseases and cholera such as FAO, UNDRO, UNESCO,
UNIDO, UNHCR and WFP.
In the joint Panel of Experts on Environmental Management of
Vector Control (PEEM), WHO, FAO, UNEP, and UNCHS have a focused
arrangement for collaboration in the area of prevention and
control of water resources development associated vector-borne
diseases. Such diseases include malaria, schistosomiasis,
Japanese encephalitis and filariasis. These diseases clearly
demonstrate the role that ecological and demographic change has
on health. Since 1990 the Panel's programme has become more field
oriented with activities in promotion, policy formulation,
research and development, and capacity building.
The FAO and WHO co-sponsored International Conference on
Nutrition (ICN), held in 1992, strongly emphasized the role of
adequate nutrition in combatting and preventing infectious
diseases and non-communicable chronic diseases and the importance
of nutrition in improving immunity, increasing efficacy of
vaccines and reducing the incidence and severity of infectious
diseases.
Food is very often the vehicle for transmission of organisms
causing communicable diseases (e.g., Vibrio cholera 01). The ICN
Plan of Action for Nutrition, inter alia, identifies the
prevention of foodborne diseases as one of the major strategies
for overcoming malnutrition. The inclusion of food safety in
national action plans for communicable disease control -
sustainable development is being pursued more vigorously.
FAO provides assistance in building capacities for improving
food safety services and developing national plans for nutrition
and nutrition education programmes for the promotion and
protection of health. Assistance to countries affected by the
recent cholera epidemic in Latin America and Caribbean Region
aims at promoting the implementation of appropriate measures to
prevent food and water contamination and to improve hygienic
practices among food handlers and the general public.
A technical meeting was held in October 1993 by WHO in
Manila with the participation of FAO on the subject of foodborne
parasitic infections. The parasitic trematodes are found in
foods: freshwater fish and shellfish, particularly, but also in
snails and various edible plants. Their economic impact is
considerable with direct and indirect losses running into
millions of dollars. A coordinated strategy between the
agriculture, aquaculture and health sectors to reduce parasitic
infections transmitted in plants and in fish and crustaceans was
developed and agreed upon. Representatives of the commercial
fishing industry have pledged their support to this strategy.
WHO and UNDP have carried out joint missions to several
countries this past year. A UNDP regional project for
strengthening the multisectoral and community responses to the
HIV epidemic in Asia and the Pacific was formulated and is being
implemented in close consultation with WHO. WHO collaborated
with the World Bank in the design and implementation of regional
seminars on AIDS prevention and care policies for high-level
policy-makers.
Another recent development is the establishment of a Task
Force on Tropical Diseases and the Environment by the Special
Programme for Research and Training in Tropical Diseases (TDR).
This programme is co-sponsored with WHO by UNDP and the World
Bank with WHO serving as the Executing Agency. The Task Force
will fund field research dealing with assessment of the magnitude
and direction of correlation between changes in agroecosystems
and risk of tropical diseases, identification of options for
intervention, economic valuation of impact of environmental
changes on social welfare and human health, and policy
formulation and reform.
UNICEF and WHO have initiated collaborative efforts in
support of health mapping and geographic information systems
(GIS) in the context of the WHO's Dracunculiasis Eradication
Programme with particular attention to Africa where an estimated
22,000 villages are involved. Information on other tropical
diseases will be linked to this effort. The WHO programme of
control of tropical diseases with FAO will be bringing together
data on human and animal trypanosomiasis (sleeping sickness)
along with their vectors to be incorporated in a GIS system.
UNITAR has been approached for training of national staff in the
use of GIS in decision making.
FAO and WHO are elaborating a joint proposal as a follow up
to the decade old FAO training project based in Lusaka on the
control of tsetse and animal trypanosomiasis. The new project is
entitled Training in Trypanosomiasis Control to support
sustainable agricultural development.
FUTURE DIRECTIONS
Effective communicable disease control requires judicious
use of preventive and promotive efforts using a community-based,
participatory model, broad environmental health interventions to
improve living conditions, housing and water and sanitation, and
improved health services. The concerned agencies of the UN
system should increase their collaborative efforts with the
national disease control programmes to develop more
cost-effective mixes of these complementary control strategies.
Moreover, monitoring and surveillance of emerging infections, as
variously exemplified by resurgence of tuberculosis resistant to
treatment, Cryptosporidium in municipal water supply systems or
Hantavirus infections spreading from rodents to man, will require
collaboration between UN and national agencies.
As noted in the Report of the Secretary-General to ECOSOC
concerning "malaria and diarrhoeal diseases, in particular
cholera" (cited earlier): "For each of these problems (disease
control and prevention), there is a balance between the
effectiveness of investments narrowly made for specific disease
interventions (for example drug therapy for malaria or case
management for diarrhoea) and the effectiveness of broader
investments in infrastructure (balanced between specific health
infrastructure investments, for example training of health staff,
strengthening epidemiological surveillance and rehabilitation or
construction of health facilities, and broader investments, for
example, in food safety, water or sanitation, primary education
or education of mothers). That level of resources which might be
appropriate, as well as the balance between narrow and more
general investment, is different in each country, underlying the
need for effective country-level decision-making."
According to the World Bank Development Report 1993, "Too
little (government spending) goes to low-cost, highly effective
programs such as control and treatment of infectious diseases and
of malnutrition". The agenda for action outlined in this report
calls for increased investment in "public health activities".
As a follow-up to the ICN, FAO and WHO are encouraging
international collaboration between agriculture, health and other
relevant sectors to prevent and control infectious diseases,
especially zoonoses, and to ensuring continued access by all
people, especially the socially and economically deprived groups,
to sufficient and sustainable supplies of safe foods for
nutritionally adequate diet.
C. PROTECTING VULNERABLE GROUPS
ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM
Many, though not all, of the vulnerable groups have received
a high level of attention with respect to health protection,
promotion and care with the involvement and close collaboration
of the agencies and organizations of the United Nations system,
virtually all governments and a wide spectrum of nongovernmental
organizations. While each of the agencies has set goals relevant
to the health and development of women and children, FAO, WHO,
UNICEF and UNFPA have set Common Goals which provide the
framework for in-country collaboration with respect to the health
of women and children.
WHO and UNICEF, in follow-up of the Declaration and Plan of
Action from the World Summit for Children, have established a set
of indicators and a global monitoring framework that includes the
dimensions of the health, education and nutrition of children,
with particular note of the girl child. These goals have been
reiterated and reinforced in the Declaration and Plan of Action
of the FAO/WHO sponsored International Conference on Nutrition
(ICN). Many of these goals, particularly focusing on the issues
of equity and human rights relevant to the vulnerable groups,
have been reiterated and amplified in such forums as the
International Conference on Human Rights and the International
Forum on Health, Accra. WHO has established an Global Commission
on Women's Development and Health.
National plans of action are being developed in most
countries, with the support and encouragement of UNICEF, FAO,
WHO and other agencies as a follow-up of the Child Summit, the
ICN and other international and regional initiatives. The Bamako
Initiative, with the support of UNICEF and the African region of
WHO has increased its coverage and effectiveness in circumstances
where the basic principles of government-community partnership,
and the decentralization of authority, responsibility and
management of resources have been followed.
WHO and UNICEF have initiated the development of an
integrated approach to the management of childhood illness.
Globally, pneumonia, diarrhoea, malaria, measles and malnutrition
cause almost three-quarters of deaths in children under five
years of age in developing countries. Feasible case management
interventions exist for these illnesses. A fully integrated
training package which addresses these conditions is currently
under development.
UNICEF and WHO have also begun to develop a joint strategy
for hygiene education in water supply and sanitation in the
1990s. Moreover, the UNDP/World Bank Water and Sanitation Program
and WHO are collaborating on hygiene education in Africa and
Asia. The purpose of hygiene education is to support behavioural
changes that will enhance the health effectiveness of improved
water and sanitation facilities.
WHO and UNESCO, on advice from the ACC Sub-committee on
Nutrition, have joined in an effort to improve the health of
school children through improved school environments. Poor
lighting, poor ventilation, lack of water supply, hand washing
and toilet facilities and many other problems are the focus of
this effort.
WFP food aid is provided to encourage greater and more
regular attendance of mothers and young children at health
centres which provide such services as immunization, pre-natal
and post-natal care, diarrhoea treatment, family planning and
health and nutrition education. When feasible, WFP tries to
combing such human resource development activities with other
activities that provide poor people with opportunities to
increase their income-earning potential.
The Seventh WHO Expert Committee on Maternal and Child
Health, with the assistance of a number of agencies, has recently
completed an in-depth review of progress with respect to the
health and development of women, children and families. Greatest
progress globally is noted in those countries and communities
where programmes address the issues of quality of care and the
genuine involvement of families and communities in the planning,
implementation and evaluation of health services and programmes.
The issues of vulnerability and environmental concerns were
addressed as well.
A number of international legal frameworks relevant to
Agenda 21 and vulnerable groups are being reinvigorated and
actively pursued in collaboration with other agencies within the
UN system. These include, the Convention on the Elimination of
All Forms of Discrimination Against Women (CEDAW), the Convention
on the Rights of the Child, and the ILO Conventions on Child
Labour(Convention 138), on Tribal and Indigenous
Populations(Convention 107) and Maternity Protection. There is
increasing collaboration among the organizations and agencies of
the United Nations system in the monitoring, reporting and
follow-up of these instruments. There has also been an increase
in the collaboration with NGOs.
FUTURE DIRECTIONS
The conclusions of the MCH Expert Committee underlined the
importance for a focus on the improvement of the quality of care
by the services being provided and not extending poor quality
care that will not have an impact. The fragmentation of care
should be avoided, and a particular focus should be placed on
reproductive health, including the environmental and toxic
hazards to reproductive health. Operationally, a major emphasis
is placed by the Expert Committee on decentralization of
authority, responsibility and financial management to local
government and community levels, with participatory approaches
being adopted in the identification of priorities, improvement of
health team functioning and in evaluation.
The UNFPA's experience suggest that integrated MCH
programmes need to be strengthened in order to reach poor
minorities, women, non-married women, adolescents and men in
providing family planning information and services.
Hard-to-reach populations in typical MCH programmes are often the
same groups at risk of STD/HIV infection. Extra efforts are
needed in designing and implementing new models of service
delivery to meet the reproductive health needs of this
substantial high-risk population. These include a concern with
sexually active persons, the provision of services for young
adults, a focus on health and responsible reproductive behaviour,
the utilization of IEC for behavioural change, and the
distribution of barrier methods to prevent STDs and unwanted
conceptions. Commonalities in training and modes of service
delivery suggest that MCH/FP programmes and STD/HIV services
should seek to work together as much as possible in a range of
activities from coordinated planning to integrated services.
Education and information provide the base of knowledge and
skills that can equip individuals, families and communities to
make positive health choices. However, the choices available to
people depend upon the accessibility of health care and services.
There is much potential for basic (community) education to
respond to local health and environmental problems especially
those affecting children and women. Basic education programmes
should be assessed in terms of their responsiveness to community
needs and expectations and in their effectiveness in promoting
communities to develop their own basic services and people to
learn new skills that will help improve the quality of their
lives. Basic education should encourage self-reliance and civic
participation in the social development process.
The role of government should be to provide a supportive
environment for family and community-based care and to provide
direct services when additional care is needed. Caring should
recognize the dignity and rights of vulnerable people. Actions
to improve the care of the socioeconomically deprived and
nutritionally vulnerable will be most successful if they are
sensitive to the particular needs and traditions of a local
community and respond to these. The ICN Declaration and Plan of
Action encourages governments to work in a collaborative manner
with local community groups, the private sector, and NGOs.
In UNICEF's 1993 State of the World's Children report,
vulnerable groups and the environment are brought together and
linked with population growth to form the "poverty, population
growth and environment" or PPE spiral. An adequate response to
the PPE problem must include:
(1) The prevention of common diseases and disabilities, and
a steep reduction in both severe and moderate malnutrition;
(2) Rapid progress towards at least a primary education for
all children, and especially for all girls;
(3) An unprecedented worldwide effort to improve the lives
of women in poor communities - their health and education, their
status and choices, their rights and opportunities;
(4) The making available of family planning information and
services to all who need them.
D. MEETING THE URBAN HEALTH CHALLENGE
ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM
The UN agencies are deeply involved in efforts to improve
the capacity of municipal governments to manage the urban
environment and improve living conditions in cities. Efforts to
strengthen health systems for rapidly urbanizing communities,
particularly in cities of developing countries, have increased in
recent years. Nevertheless, the number of cities in which the
urban health challenge is being met adequately remains small in
comparison to the total need.
The WHO Healthy Cities Programme, the UNDP LIFE Programme,
the ILO Labour Intensive Public Works Programme, the Metropolitan
Environment Improvement Programme and Metropolitan Development
Programme of World Bank/UNDP, the Sustainable Cities Programme of
UNCHS, the CITYNET/Asia-Pacific 2000 Programme of ESCAP/UNDP, the
Megacities Programme, the Metropolis Programme, and the WMO
Tropical Urban Climate Experiment (TRUCE) are some of the
initiatives at the international level.
Linkages have been established among UN agencies with all of
these to ensure that the municipal planning exercises that are
common to all place due emphasis on protection and promotion of
health. The World Health Assembly Technical Discussions in May
1991 on "Strategies for Health for All in the Face of Rapid
Urbanization" has been a milestone in this development.
A collaborative project has been undertaken to increase
awareness, identify issues and experiences and promote the
development of health programmes in several cities in various
regions of the world. This project involves WHO, UNICEF, UNDP,
METROPOLIS, Rockefeller, several donor agencies, and research and
development institutes of both developed and developing
countries. The aim is to develop a network of supporting
institutions that will be able to mobilize needed technical and
financial input in the implementation of projects developed by
the participating cities.
The "supportive environments" or "settings approach" has
been widely promoted both as part of the healthy cities programme
and as a health promotion programme. A fine example of this
approach is the national school health programme in Ghana. By
focusing attention of relevant Ministries and authorities on
health conditions in key settings (village, school, workplace,
city, markets, etc), the supportive environments approach is
emerging as an effective and practical means of intersectoral
action.
The role of health institutions, particularly health
centres, in the implementation of primary health care in urban
areas is receiving increased attention in light of
decentralization, particularly in big cities. Based on promising
experiences in a number of cities, it is proposed that at least
one health centre be designated in each urban district as a
"reference health centre". Studies are being carried out in eight
cities to further develop this approach.
The FAO programme on street foods aims at promoting the role
of the informal sector in providing a safe, nutritious and
economically accessible food for the urban populations in large
cities in both developed and developing countries. It focuses on
promoting hygienic practices in food preparation and handling
through appropriate educational programmes, and on improving
environmental sanitation in food vending areas.
FUTURE DIRECTIONS
Inequitable distribution of resources, irrational
duplication and overlapping of functions, limited authority at
local level, and uncoordinated efforts between public, private,
voluntary and nongovernmental organizations, still dominate the
urban scene. The experience gained in implementation of the
above-mentioned programmes should be used to overcome these
constraints and problems. What has been learnt is that the
"partnership approach", common to all these programmes, where
communities, NGO's, Municipalities and local health departments
jointly address problems using resources that essentially are
mobilized locally, is the best option for urban development.
It is increasingly recognised that many urban health
problems are based in social issues such as social
disintegration, unemployment and poverty. These need to be
addressed more strongly in the formulation of municipal health
plans. These social issues touch all aspects of urban
development, so a greater emphasis will need to be placed on
integrating health with other urban development activities. In
this context, a case can (and will) be made that a proportion of
the budget of every urban development activity should be
allocated for the protection and promotion of health.
Health in urban areas cannot, however, be improved without a
healthy human environment. Air and water quality, garbage
disposal, noise, etc., have to be addressed adequately as a
prerequisite to better health of the urban dweller, particularly
those living in poor peri-urban quarters. Consequently, there is
inherent linkage between the activities to reduce health risks
from environmental pollution and hazards and the urban health
programmes (see programme area E below).
There is also increased recognition being given to the
importance of having adequate information on intra-urban
differences. Simplified protocols should be further developed
and more widely used by local authorities to establish base-line
assessments of urban health, to monitor progress and to collect
and analyze data from different socio-economic population groups.
Incorporation of new information technologies, especially
geographic information systems, should be pursued in conjunction
with other managerial capacity-building efforts.
Increased efforts will be made to expand national and
international collaboration networks and to share experiences and
"models of good practice".
Finding additional funds to pursue the objectives of this
programme area will need to be better coordinated among the UN
agencies involved to prevent unproductive competition among the
agencies for bi-lateral funding of projects in the same urban
settings.
E. REDUCING HEALTH RISK FROM ENVIRONMENTAL POLLUTION AND
HAZARDS
This programme area interlinks with several other chapters
of Agenda 21, and particularly with chapters 8 "Integrating
environment and development in decision-making", 9 "Protection of
the atmosphere", 18 "Protection of freshwater resources", 19
"Toxic chemicals", 19 "Hazardous wastes" and 20 "Solid waste and
sewage".
ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM
UNEP, FAO and WHO have been in the forefront of several
activities in this field that have provided a framework for
strengthened action at international and national level. These
activities include the health component of GEMS (the Global
Environment Monitoring System), the HEALs project (Human Exposure
Assessment Locations) and the Global Networks project for
education, training and research. In addition, UNEPs APELL and
Cleaner Production projects have provided industry with essential
information and advice that has reduced pollution and health
risks. Each of these activities are active in a large number of
developing countries and have created collaboration between
developed and developing countries as well as among developing
countries.
Health-based criteria for air-quality, drinking-water
quality and coastal waters have been developed through a
scientific evaluation and risk assessment process. These provide
the grounds upon which governments are building their national
standards, and local authorities their pollution control
programmes.
Environmental health impact assessments have become a pre-
requisite for major development projects with important
environmental impacts.
In support of preparing the grounds for an holistic approach
to pollution risk reduction, a series of pilot countries in all
world regions have been undertaken. These are expected to lead
to the development of comprehensive risk analysis, pollution
source identification and prioritization of remedial action
needed. Ultimately, these should result in the formulation of
cost- effective health protection components and
prevention/control measures.
UNCED has given a new impetus to these existing activities.
One of the main new initiatives has been intensive collaboration
between national and international agencies in preparing National
Sustainable Development plans for a series of countries. UNDP,
UNEP, FAO, WHO, the World Bank and other international agencies
and NGOs have all been involved. The World Bank has coined the
term "National Environmental Action Plans". WHO is working with
selected countries to ensure that the Health sector is an active
participant in the process together with all other sectors, and
some of these countries have called their plans "National plans
for Health and Sustainable Development". Other terms are also
used.
In order to put these plans into practice, more detailed
plans for specific components need to be developed, and guidance
and incentives for intersectoral action in the field is required.
WHO has started to work with countries to formulate a rolling
"Health and Environment" planning process. This would have a
monitoring and assessment part, a management and pollution
control part, a human resources development part and a research
part.
At the international level, WHO is linking with UNDP, the
World Bank, Regional Banks, UNEP, ILO, FAO, UNESCO, UNIDO, IAEA,
and others as appropriate, to create partnerships at country
level among sectors that have in the past communicated
independently with each international agency. The ultimate aim
is to establish an intersectoral "problem-solving team spirit" at
the local and national level, in order that the planning items
can be put into practice without delay and sectoral barriers.
In order to reduce health risks from environmental pollution
the new approaches at national and international level will
include taking advantage of cross-linkage between initiatives
that focus on specific target groups. This includes the "Healthy
cities project", "Supportive environment projects" and others
described in other parts of the report on chapter 6.
FAO is working with countries to ensure that access to
adequate and safe food supplies, education and related services
can and are achieved by ensuring sustainable measures that are
environmentally sound. This includes the consideration of
providing incentives and motivating farmers to adopt sustainable
and efficient practices.
A new activity in the monitoring and assessment area is a
joint UNEP/WHO project to develop improved methodologies and
guidance for linking data on environmental quality and health
status of populations exposed. Indicators for measuring
environmental conditions rather than individual pollutants or
stressors is seen as a component of the evaluative process. The
linkage analysis will be used to develop environmental health
indicators suitable for monitoring of progress in sustainable
development and Health For All implementation. It will also be
used to improve the methodology for environmental health impact
assessment. Due to different priorities, different indicators
may be used in different countries, or even within countries, but
a core minimum set will ensure that national, regional and global
aggregation of information can be created. This project will be
closely linked to the UNEP/UNSTAT activities to harmonize
environmental statistics and sustainable development indicators.
FUTURE DIRECTIONS
The intersectoral work at field level needs to be based on
up- to-date information about past, ongoing and planned
activities in the same country, so that national and
international agencies can avoid duplication and waste.
Intersectoral collaboration for problem-solving at the local
level needs to be further developed and tested. The area of
information can be the testing ground for such an approach. The
procedures for environmental health assessment and management
should be streamlined down to a limited number of elements, using
the core sciences, such as microbiological, chemical and physical
measurements, statistics, epidemiology and social sciences.
The continuing major void in information on health-related
environmental quality and effects on health in developing
countries must be dealt with. Hard and accurate information is
needed for building general public awareness and support,
obtaining political support and providing the scientific basis
for national legislation, standards and programmes. The
international initiatives to date, primarily through the Global
Environmental Monitoring System (GEMS), provide an established
framework for dealing with this problem, but such efforts need
considerable strengthening.
As is said in essentially all relevant chapters of Agenda
21, emphasis now must be placed on prevention of causes of
environmental degradation. This is also true for the activities
considered in this chapter. Opportunities exist through land use
planning, transportation planning, behavioural changes, etc.
Agreement that new development projects should undergo an
environmental health impact assessment should be enforced. It is
up to organizations such as UNDP, the World Bank and others to
see that this is done.
SECTION III: SCIENTIFIC AND TECHNOLOGICAL MEANS
The five programme areas covered in section II stratify the
overall health conditions of populations by location and social-
economic characteristics. All of these strata have been and will
increasingly be subjected to dramatic change:
* in their relative size and location,
* in the extent of the risks causing these conditions.
Chapter 6 of Agenda 21 identified a series of scientific and
technological means to improve the understanding, forecasting and
management of the change processes affecting these population
groups. These can be grouped as follows:
(1) More effective planning processes and methods for
strategy design at national, district and local levels;
(2) Improved information (data) management and
communications;
(3) Models and other tools which facilitate the analysis of
the variables in health problem situations, and which assist the
assessment of costs and impacts of possible solutions and
intervention strategies;
(4) Information monitoring, analysis and sharing at the
international level, including dissemination of knowledge,
technology and resources through TCDC.
HEALTH PLANNING AND STRATEGY DESIGN
International and national health and development planning
methods and practice have gone through cycles of development over
the last several decades. The current situation is characterised
by a continuing desire for more intersectoral planning and
strategy development, but with few successes. There is also a
continuing desire to ensure that cost and effectiveness
considerations are attached to all political goal setting, such
as Health For All and sustainable development. Nevertheless,
there remains in many countries a negative assessment of the
value, and therefore the need to invest in extensive health
planning processes.
On the other hand several recent international developments
signal an opportunity for re-emphasizing health planning and
related activities with the expectation of near-term benefit:
(1) The use of cost-effectiveness in the design of health
strategies and services and a method for monitoring the health
state of a population which helps establish priorities in terms
of the "burden of disease" in the World Banks World Development
Report of 1993 on Health and Development.
(2) The concept of "new Public Health Action" which implies
among other things that health planning processes can and should
review and revise the extent of public responsibility in health.
(3) The "decentralization" of health planning and the use
of health data and epidemiology by district staff and community
leaders as they devise their own approaches for health promotion
and protection (eg. through district problem-solving processes
and micro-planning).
(4) The growing experience with "rapid assessment"
procedures for situation analysis and programme monitoring and
evaluation.
(5) The initiation by WHO and UNICEF of a joint monitoring
programme for water supply and sanitation as a means of building
national capacity to monitor and manage water and sanitation
development.
Thus, there seems to be an opportunity for health planning
methods to be further developed and appropriately applied through
revitalized international partnerships which address the agreed
needs for equity, cost-effectiveness, implementability and
involvement by the community.
IMPROVED HEALTH DATA MANAGEMENT AND COMMUNICATIONS
The rapidly advancing micro-computer technology and data
communications capability offers considerable potential for
improvement in the management of the extensive amounts of data
generated by and felt required for the delivery of health
services. While some progress is being made, the rarity of
efficient health data management in most countries is striking.
The tremendous under-analysis and use of routinely generated
health data continues despite the means for selectively capturing
and analysing it for monitoring, evaluation and control purposes.
Again, concerted international partnership and action should
be able to foster the use of available, inexpensive computer
technology for improved heath data management and communications.
Specific types of technology enhancement include:
(1) development of health indicators to monitor and
evaluate access, equity of access and use, efficiency and quality
of health services;
(2) guidance in the design and management of large data
bases and training in the operation of computerized health
information systems;
(3) practical use of facsimile and electronic mail
communications;
(4) special computer applications such as geographic
information systems, patient flow analysis and data trend
analysis;
(5) improved epidemiological surveillance to identify
environmental hazards and to forecast the spread of communicable
diseases;
(6) an epidemiological basis for developing, and then
evaluating new disease control strategies.
HEALTH MODELLING
The availability of user-friendly modelling packages
associated with the power of sophisticated data analysis and
dynamic modelling has opened up the possibility of modelling to
Everyman. Collaborative efforts among interested agencies and
institutions should focus on practical guidance for national
health administrations in the use of computer modelling to:
(1) Analyze the complicated cause and effect relationships
that exist in any health problem situation;
(2) devise and test the cost-effectiveness of potential
interventions within a problem situation;
(3) forecast and design future scenarios in the health
situation and system.
One collaborative effort that could lead to the development
of practical health-environment modelling methods is the current
WHO/WMO/UNEP project to produce a book on Potential Health
Impacts of Climate Change. This activity takes place in close
coordination with the impact assessment work of the
Intergovernmental Panel on Climate Change (IPCC), whose
climatological modelling scenarios for 2020 and 2050 serve as
baseline material.
INTERNATIONAL GENERATION AND SHARING OF HEALTH INFORMATION
The same computing and communications technology that can do
so much to benefit data management in countries is also available
to serve the community of nations at the global level. Reference
has already been made to GEMS. Other areas for sharing and using
globally available data to greater advantage include:
(1) WHO and the Centres for Disease Control, Atlanta are
exploring the possibility of a global monitoring of emerging
infection and changing disease patterns through the use of
national collaborating laboratories and global data
communications facilities.
(2) a similar service can be provided with respect to the
rapidly advancing health and biomedical technology. A global
monitoring function can be established which, with the
cooperation of major research centres, can keep abreast of
progress and expected breakthroughs from research and development
of health technology.
(3) on a less sophisticated level, the internet and gopher
spaces of the world offer the ability to easily gather and share
evidence of the effectiveness of new health strategies and
operational approaches. What is required is the necessary staff
support to administer such international electronic clearing
houses.
(4) an inter-agency project on Databases and Methodologies
for Comparative Assessment of Different Energy Systems for
Electricity Generation (DECADES), while not specific to health,
is of relevance in illustrating the extent to which inter-agency
cooperation is possible in this area. The Secretariat is IAEA,
IIASA, OPEC, and UNIDO. Other cooperating organizations include
CEC, IBRD, OECD/NEA and WMO.
SECTION IV: HUMAN RESOURCES DEVELOPMENT AND CAPACITY-BUILDING
This programme area is closely associated with chapters 36
"Promoting education, public awareness and training" and 37
"Capacity-building".
ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM
The UN agencies actively promote and support human resources
development in countries. WHO has made a major effort in the
health field with other agencies playing important roles - FAO,
UNEP, UNESCO, UNICEF, and UNITAR, to name just a few. Financial
support has been provided by UNDP, the World Bank, Regional Banks
and a number of bilateral and other agencies.
WHO has been active in supporting and guiding national
agencies for many years. Stress is given to the relevance of
training to the work situation and efficiency of training methods
used. More recently, the work of WHO has focused on district
level staff, as they often have limited base training and few
opportunities for continuing education.
One area of importance for district level staff training has
been the provision of appropriate training materials in local
languages. The WHO Health Learning Programme has helped
establish around 30 national centres for the translation and
publication of needed training materials.
To strengthen the capacity to deal with health and
environment problems at local and national level, WHO has
developed Global Networks of teachers and researchers in the
field of health effects assessment (the Global Environmental
Epidemiology Network, GEENET) and the field of environmental
management and pollution control (the Global Environmental
Technology Network, GETNET). These networks of more than 2000
people in 130 countries provide an important infrastructure for
communication and collaboration. Specific country activities,
particularly training workshop on priority topics, are sponsored
via the networks and support and collaboration has been
established with UNEP, UNESCO, the World Bank, and bilateral
cooperation agencies.
The ultimate aim of the networks activities is to facilitate
the development of sustainable training activities within country
institutions. Teacher training programs have therefore been
started together with UNEP and ILO. In the future, it is
essential to link the different training activities at national
level into a common planning framework.
The development of human resources in various fields related
to food and agriculture is an essential component of FAO
programmes. In relation to health, and as a follow-up to the
ICN, emphasis has been given to the training of local health
workers and nutritionists in the diagnosis and treatment of
nutritional diseases including micronutrient deficiencies and on
integrated approaches to improve household and community
nutrition. Emphasis has also been given to the training of food
control personnel and managers in various aspects related to this
activity.
One area of importance is the development of high-level
expertise on the priority environment and health issues for each
country, in order that national consultants can be provided for
as many tasks as possible related to development projects.
FUTURE DIRECTIONS
The development of comprehensive national strategies and
human resources development plans for the health and environment
field is a priority and should be linked to the development of
national Agenda 21 plans as a subsidiary process. These plans
should highlight what knowledge and skills are needed, who should
have them, how they should learn it, and who should facilitate
the learning (who should teach). Internationally sponsored
training should be implemented in order that national training
developments are encouraged and facilitated, and should lead
towards sustainable training. Funding of training should be
linked to other development investments, just like funding for
other infrastructure and resources is seen as a part of an
investment.
Another new feature of human resources development should be
a more demand-driven approach rather than supply-driven. WHO is
planning to offer its' environmental health training services in
this way in the future. This means that modular training
workshops and courses will be developed for adaptation by
national programmes when and as needed. Country agencies can fit
these into their national HRD plan implementation, and will seek
possibilities to link specific training events to development
investments in order to fund the event.
International agencies need to coordinate their programmes
better and make arrangements for intersectoral training
opportunities, instead of duplicating training courses for
different sectors.
Numerous international agency information and guidance
materials are produced without sufficient follow-up activities to
make them used as intended by the target groups. Many of these
materials could be used as resource materials for training,
together with custom-made training materials based on country
priorities. A collaborative effort to harness these written
resources for environmental health training will be initiated by
WHO, as a part of the collaboration on environmental education
with UNEP, UNESCO, ILO, UNITAR, UNIDO and other agencies.
UNESCO is concerned with the future role of universities in
societies experiencing many challenges and profound crisis.
Universities almost everywhere have been slow to accept
responsibility for research and teaching in interdisciplinary
fields (such as health and the environment) since they have long
been organized by academic disciplines each with its own
department. Universities must face the challenge of breaking
down these traditional boundaries to create interdisciplinary
programmes that respond to pressing health and environmental
problems. This also means adopting open, creative and active
methods of learning. Active and participative learning can
produce relevant experiences and enable students to learn from
them. New collaborative initiatives have been taken for the
promotion of innovative professional training approaches by
UNESCO, UNEP and WHO.
SECTION V: DECISION-MAKING AND FINANCIAL IMPLICATIONS
In "Our planet, our health", decision-making in the field of
health and the environment is assessed in the following terms:
The maintenance and improvement of health should be at the
centre of concern about the environment and development. Yet
health rarely receives high priority in environmental policies
and development plans, rarely figures as an important item in
environmental or development programmes, despite the fact that
the quality of the environment and the nature of development are
major determinants of health.
This assessment was made in 1991. It still applies today as
regards the participation of Ministries of Health (MOH) in the
decision-making process of Agenda 21.
Since its origin, WHO has worked with its Member States to
strengthen Ministries of Health (MOHs). With the adoption of the
PHC approach at Alma-Ata, with its strong intersectoral
implications, the need for strengthened MOHs has grown in
priority. But the reality in many countries, is that these
Ministries play only a relatively small part in the affairs of
overall national health systems. The MOH in many developing and
developed countries does not have a policy or programme, or the
capacity to influence the development of key sectors such as
urban development, water and sanitation, food and agriculture,
education, etc. This "gap in leadership" must be overcome if the
health goals outlined in Agenda 21 are to be realized. No simple
formula exists. The national machinery that is set up to oversee
the implementation of Agenda 21 must address this problem as a
matter of urgency.
As noted in Chapter 8 of Agenda 21, prevailing systems for
decision-making in many countries tend to separate economic,
social and environmental factors at the policy, planning and
management levels. This situation still largely prevails.
Traditional incentives dominate; new economic incentives and new
systems for integrating environmental and economic accounting
have not yet begun to be put in place. Since traditional
economic thinking and analysis has often ignored adverse impacts
of "development" on human health and the environment, it is
essential that the new systems for integrated environmental and
economic accounting to be developed for sustainable development
incorporate health concerns.
Health budgets are largely dominated by the provision of
curative services. Consequently, current financial incentives
within the health sector are more tied to the magnitude of
illness than its prevention. Furthermore, attempts to look at
health costs and needs from a broader multi-sectoral perspective
are handicapped by the near total lack of relevant data.
Two important factors contribute to the state of ignorance
concerning health needs and costs:
(1) man-made changes to the environment are rarely made
with health objectives in mind; consequently, little attention is
given to the assessment of any impact on health, and thus little,
if any, attention is given to the costs of reducing risks
associated with these changes.
(2) the health-sector, as such, is poorly positioned to
monitor the impact on human health of changes introduced by other
sectors, even where it is mandated to undue the damage done by
others.
In short, while much is known about what is spent on
curative and personal care, the contribution of changes to the
environment or efforts to promote health through behavioural
changes are at best only understood qualitatively.
Further consequences of the current situation are as
follows:
(1) potential health risks are not "costed" and the
services provided by other sectors are not "priced" to reflect
these risks;
(2) the monitoring of such health risks is not budgeted for
at a level comparable to the threat they pose to human health;
(3) the monitoring of health risks is not built into major
developmental projects.
These points can be illustrated by examples drawn from the
water resources development field:
(1) Where the per capita water supply allowance of a large
city is significantly increased, the cost of the project is not
increased to cover new health hazards due to the environmental
pollution resulting from increased quantities of used water.
(2) Where serious epidemic outbreaks occur (especially
cholera), it is public health resources that are expected to
control the outbreak even though these resources are often
inadequate to cope even with the task of surveillance of drinking
water quality.
(3) Where water development projects through flow
regulation and drainage shape the local epidemiology of many
diseases, for example, malaria and schistosomiasis, the potential
of increased health risks is rarely incorporated into the
engineering and public works infrastructural cost of these
schemes.
Various solutions to these problems have been proposed which
suggest how the financing of health should be looked at in the
context of environment and sustainable development. For example,
if the health authorities could subcontract surveillance to
private laboratories, or undertake any structural improvements
which would allow them to carry out this task themselves, they
could guarantee the delivery by the water authorities of a
potable product. The cost would be but a minor part of the total
expenditure required to supply water, and it could be
incorporated in the selling price, as consumers would probably be
more willing to pay the full cost of the service, if they were
convinced of its value and health benefits.
Also, capital costs associated with major water development
projects could reflect total costs in a more realistic way: a
proportion of the income generated by environmental improvements
could be used to finance the costs of health maintenance which
includes screening, surveillance, prevention, treatment,
education and the control of disease vectors.
These examples, which relate to water development, apply to
all other sectors which contribute to changes in the environment
of importance to human health: air, shelter, land, forests,
coasts, etc. For human health to be both the core and the
objective of sustainable development, the financing of health
must account for all such sectors. Only in this way will the
most cost-effective health interventions be determined and given
highest priority.
For such an approach to health financing to be realized, it
is essential that the other sectors concerned are involved
financially, technically and administratively in identifying and
developing these interventions. The involvement of other sectors
to such an undertaking should be commensurate with the level of
inter-dependence judged to be present. Thus, for example, where
communicable diseases pose a major burden of ill-health and are
heavily associated with water development projects, it would be
reasonable for the water development sector to be expected to
play a significant role in controlling such diseases. The total
contribution to health through such multi-sectoral involvement
can be considered and budgeted as an environmental health line in
the national health plan.
In WHO's contribution on Financing of Health, the
environmental health line included vector control, air pollution,
safe water, other pollution, hygienic collection, reuse and
disposal of wastes, hazards from toxic chemicals, protection of
natural resources and promotion of the environmental
infrastructure. The total "cost" associated with this line
amounts to less than 12% of the 51 billion US$ per year "cost of
health" quoted in Chapter 6 of Agenda 21. This figure, however,
should not be taken as a definitive estimate of how much should
be invested in the environment to achieve better health. Rather,
it is an amount to ensure that there will be the necessary funds
to develop multi-sectoral linkages, put in place environmental
monitoring and surveillance systems, and, in time, to develop
cost- effective instruments which can be integrated in the
programmes of other sectors.
According to the World Development Report 1993, a total of
US$ 170 billion was spent on health in the developing countries.
Thus, at least in gross quantitative financial terms, the costs
for implementing the activities outlined in Chapter 6 of Agenda
21 can be met. The changes involved, however, as indicated
above, will require considerable reform within the health sector
and across all health-related sectors.
SECTION VI: SUGGESTED DEVELOPMENT STRATEGIES FOR THE FUTURE
Chapter 6 of Agenda 21 identified the essential activities
that need to be implemented. But Chapter 6 did not address the
fact that much reform is needed for such a programme of
activities to be realizable. Four "lines of reform" emerge from
the above analysis:
(1) Community (Health) Development: protecting and
educating vulnerable groups as part of more holistically
conceived community development programmes;
(2) Health Sector Reform: Ministries of Health increasing
allocation of resources to most cost-effective programmes;
(3) Environmental Health: increasing understanding of
sectoral-linkages with health and mobilizing action in other
sectors accordingly;
(4) National Decision-Making and Accounting: strengthening
health representation in national decision-making and
incorporating health and its financing in new accounting systems
for sustainable development.
Fortunately steps have already been taken to promote reform
within the health sector, as indicated earlier. The additional
reforms are needed to ensure that health is incorporated in all
aspects of national sustainable development. Only in this manner
will the pursuit of improved human health be a positive driving
force for sustainable development.
The CSD called upon the Task Managers to prepare "analytic"
reports which would highlight "unnecessary duplication", "gaps
and opportunities for cooperation and joint programming",
"assessment of relevance, strength and usefulness of various
programmes and activities", and "organizational responsibilities
and allocation of tasks on the basis of expertise and competitive
advantage". This has been done in the preceding sections, but
only to a partial degree. The analysis has not been carried out
to its "logical conclusion", since any conclusion concerning, for
example, "unnecessary duplication" might be counterproductive.
It was felt that a logical delineation of organizational
responsibilities might stall current efforts among UN agencies to
support health sector reform. Without health sector reform, it
is difficult to imagine the other reforms identified having any
chance of success. Instead, the CSD is called upon to help the
process of change by confirming that the lines of reform
identified should be actively pursued by all relevant UN
agencies.
The CSD can further stimulate movement in the direction
outlined through special action, e.g. calling upon Governments to
host meetings to elaborate the reform process in more detail,
calling upon donor agencies to ear-mark funds for this process in
countries that are actively implementing sustainable development
policies, and establishing special working groups to monitor
progress within the UN system to ensure that the reform called
for at national level is leading to comparable reform within and
among the various agencies involved.
A common understanding of sustainable development does not
exist. Consequently there is a strong risk that the
revolutionary changes called for by Agenda 21 will rapidly be
lost sight of. This risk is particularly present in the health
sector where environmental health has rarely received adequate
attention. The active support of the CSD is required in carrying
out the reforms listed above to ensure that the full potential of
Agenda 21 is realized.

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Date last posted: 1 December 1999 12:18:30Comments and suggestions: DESA/DSD